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Poor R-wave progression and all-cause mortality in adults without coronary artery diseaseHeart rhythm pattern shows borderline link to death risk

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Key Takeaway
Note that poor R-wave progression was not significantly associated with CV death or MACE in this cohort.

This cohort study analyzed 6,323 adults from the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of baseline coronary artery disease. The study population had a mean age of 61.9 ± 10.2 years and was 54% women. Participants were evaluated for poor R-wave progression (PRWP), defined as R-wave amplitude <= 3 mm in V3 with RV3 > RV2, compared to those without PRWP.

During a median follow-up of 14.1 years (IQR, 13.5-14.7), the study observed a borderline association with all-cause mortality (HR 1.31; 95% CI, 0.99-1.73; P=0.059). Total deaths included 1,138 individuals, with 52 deaths (25.7%) in the PRWP group. However, when adjusted for smoking and emphysema, the estimate was attenuated to a non-significant HR of 1.19 (95% CI, 0.90-1.58; P=0.229).

Regarding cardiovascular outcomes, no significant association was found for cardiovascular death (HR 0.87; 95% CI, 0.43-1.76; P=0.690) or major adverse cardiovascular events (MACE) (HR 0.94; 95% CI, 0.57-1.54; P=0.796). A significant interaction by sex was noted for MACE (P=0.002), driven by higher stroke incidence in women.

Limitations include the fact that the borderline excess in all-cause mortality was driven by non-CV deaths and that adjustments for smoking and emphysema attenuated the estimates. In this large, multi-ethnic cohort, isolated PRWP did not confer independent risk for CV death or MACE.

When doctors look at an EKG, they often check how electrical signals move through the heart. One specific pattern, called poor R-wave progression, can sometimes raise eyebrows. For years, people have wondered if this specific signal pattern is a warning sign for serious heart problems or even death.

Researchers followed over 6,000 adults for about 14 years to find out. They looked at people who did not have existing heart disease but had conditions like high blood pressure or diabetes. The study found a borderline association between this heart pattern and all-cause mortality, meaning the risk of death from any cause. However, this link was not statistically certain, and the extra risk seemed to fade when researchers accounted for smoking and lung disease.

Crucially, the pattern did not appear to be a direct driver of heart attacks, strokes, or heart-related deaths. While there was a notable increase in stroke cases among women with this pattern, the overall link to major cardiovascular events was not found. This suggests that while the pattern is worth watching, it may not be a standalone predictor of heart disease on its own.

What this means for you:
A specific EKG pattern shows a borderline link to death risk, but not to heart attacks or strokes.

Study Details

Study typeCohort
Sample sizen = 202
EvidenceLevel 3
PublishedApr 2026
View Original Abstract ↓
Background: Poor R-wave progression (PRWP) on the 12-lead electrocardiogram has been linked to adverse outcomes. Its prognostic value in a contemporary, multi-ethnic population without baseline coronary artery disease (CAD) is unclear. Methods: We analyzed 6,323 adults (mean age 61.9 +- 10.2 years; 54% women) from the Multi-Ethnic Study of Atherosclerosis after excluding pre-excitation, major conduction disease, Q-wave infarction, and missing covariates. PRWP was defined as R-wave amplitude <= 3 mm in V3 with RV3>RV2 and was present in 202 participants (3.2%). Outcomes were all-cause mortality, cardiovascular (CV) death, and major adverse cardiovascular events (MACE: nonfatal myocardial infarction, resuscitated cardiac arrest, or stroke). Cox models adjusted for age, sex, race/ethnicity, hypertension, and diabetes. Results: Over a median 14.1 years (IQR, 13.5-14.7), 1,138 deaths, 256 CV deaths, and 515 MACE occurred. Among PRWP participants, there were 52 deaths (25.7%), 8 CV deaths (4.0%), and 16 MACE (7.9%). In prespecified models, PRWP was not associated with CV death (hazard ratio [HR] 0.87; 95% CI, 0.43-1.76; P=0.690) or MACE (HR 0.94; 95% CI, 0.57-1.54; P=0.796) and showed a borderline association with all-cause mortality (HR 1.31; 95% CI, 0.99-1.73; P=0.059), driven by non-CV deaths. Adjustment for smoking and emphysema attenuated estimates (all-cause HR 1.19; 95% CI, 0.90-1.58; P=0.229). A PRWP x sex interaction was significant for MACE (likelihood-ratio test P=0.002), driven by higher stroke incidence in women; interactions by race/ethnicity were not significant. Conclusions: In a large, CAD-free, multi-ethnic cohort, isolated PRWP was uncommon and did not confer independent risk for CV death or MACE over 14 years. The borderline excess in all-cause mortality was non-CV and diminished after accounting for smoking and emphysema.
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